Root Cause Analysis for Fall Investigations: Applying Evidence-Based Best Practices to Prevent Recurrent Falls - WEBINAR

Description

     This interactive training program equips nursing home teams with a structured, evidence-based approach to conducting thorough Root Cause Analysis (RCA) following resident falls. The session moves beyond traditional incident reporting and blame-focused investigations to a systems-thinking framework that identifies underlying contributors and drives sustainable prevention. 

     Content is aligned with current CMS guidelines, The Joint Commission standards, AHRQ fall prevention toolkits and CDC STEADI, and the National Pressure Injury Advisory Panel fall related recommendations. 

Objectives: 

By the end of the session, participants will be able to: 

· Describe the regulatory expectations and evidence-based rationale for performing Root Cause Analysis rather than simple incident reporting after every fall (CMS Phase 3 Requirements of Participation, F689 Free from Accidents). 

· Differentiate between immediate cause, contributing factors, and true root causes using real nursing home fall scenarios. 

· Identify the most common system-level root causes of falls in nursing homes, supported by current literature such as: medication-related issues, environmental hazards, inadequate post-fall huddles, communication breakdowns, and care planning gaps. 

· Implement an interdisciplinary post-fall huddle protocol within 24–72 hours that includes nursing, therapy, pharmacy, maintenance, and dietary staff to prevent recurrence for the individual resident and the broader population. 

· Integrate RCA findings into the facility’s QAPI (Quality Assurance & Performance Improvement) program to demonstrate measurable reduction in fall rates and fall-related injuries over time. 

· Document RCA investigations in a defensible, regulatory-compliant manner that withstands survey scrutiny and supports a culture of safety rather than blame. 

1.5 Hours NAB Approved

Speaker: Linda Farrar, RN, LNHA, Oklahoma Clinical Consultant, LICA MedMan